=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790166072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOME AWAY FROM HOME BEHAVIORAL HEALTH RESIDENTIAL FACILITY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2015
-----------------------------------------------------
Last Update Date | 06/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9231 W MOUNTAIN VIEW RD
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85345-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-559-6033
-----------------------------------------------------
Fax | 623-322-8622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7077
-----------------------------------------------------
City | GOODYEAR
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85338-0635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-559-6033
-----------------------------------------------------
Fax | 623-322-8622
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. TANYA MARGUERITE AYIYI
-----------------------------------------------------
Credential | LPN
-----------------------------------------------------
Telephone | 602-559-6033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | BH4584
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------